Provider Demographics
NPI:1205364007
Name:NICHOLS, TARA LYNN (CNP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LYNN
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2600 6TH ST SW STE A2-800
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44710-1702
Mailing Address - Country:US
Mailing Address - Phone:330-363-1342
Mailing Address - Fax:330-363-1361
Practice Address - Street 1:2600 6TH ST SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44710-1702
Practice Address - Country:US
Practice Address - Phone:330-363-1342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH365623163W00000X
OHAPRN.CNP.020528363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1205364007Medicaid